How to manage a 44-year-old male with hypercholesterolemia and hypertriglyceridemia?

From the Guidelines

Management of a 44-year-old male with hypercholesterolemia and hypertriglyceridemia requires a comprehensive approach combining lifestyle modifications and pharmacotherapy, with the primary goal of reducing cardiovascular risk. The patient's high cholesterol and triglyceride levels, with a cholesterol level of 335 mg/dL and triglycerides of 465 mg/dL, indicate a need for immediate intervention to mitigate the risk of atherosclerotic cardiovascular disease. Initial treatment should focus on lifestyle changes including a Mediterranean or DASH diet low in saturated fats and refined carbohydrates, regular exercise (150 minutes of moderate-intensity activity weekly), weight loss if overweight, smoking cessation, and limiting alcohol consumption 1. For pharmacotherapy, a moderate-intensity statin such as atorvastatin 20mg daily or rosuvastatin 10mg daily should be started as first-line therapy to reduce LDL cholesterol, as statins have been shown to be effective in reducing cardiovascular risk in patients with hypercholesterolemia 1. Given the patient's triglyceride level of 465 mg/dL, which is considered moderate to severe hypertriglyceridemia, adding fenofibrate 145mg daily or omega-3 fatty acids (icosapent ethyl 2g twice daily or omega-3 ethyl esters 2-4g daily) should be considered if triglycerides remain elevated despite statin therapy and lifestyle changes 1. Regular monitoring is essential, with lipid panels checked 4-12 weeks after initiating therapy and then every 3-12 months, and liver function tests should be monitored periodically. This approach targets both cholesterol and triglyceride abnormalities while reducing overall cardiovascular risk, as dyslipidemia significantly increases the risk of atherosclerotic cardiovascular disease, particularly in middle-aged men. Key considerations in managing this patient include:

• Lifestyle modifications to reduce cardiovascular risk
• Pharmacotherapy with statins as first-line treatment for hypercholesterolemia
• Consideration of additional therapies such as fenofibrate or omega-3 fatty acids for moderate to severe hypertriglyceridemia
• Regular monitoring of lipid panels and liver function tests to assess treatment efficacy and safety.

From the FDA Drug Label

Patients should be placed on an appropriate lipid-lowering diet before receiving fenofibrate tablets and should continue this diet during treatment with fenofibrate tablets. The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated. Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.

To manage a 44-year-old male with hypercholesterolemia and hypertriglyceridemia, the following steps should be taken:

• Place the patient on an appropriate lipid-lowering diet before initiating any drug therapy.
• Address any excess body weight and excess alcoholic intake, as these may be contributing factors to hypertriglyceridemia.
• Look for and treat any underlying diseases that may be contributing to hyperlipidemia, such as hypothyroidism or diabetes mellitus.
• Consider initiating fenofibrate therapy as an adjunct to diet to reduce elevated LDL-C, Total-C, Triglycerides, and Apo B, and to increase HDL-C.
• The initial dose of fenofibrate for primary hypercholesterolemia or mixed dyslipidemia is 160 mg once daily, while for severe hypertriglyceridemia, the initial dose is 54 mg per day to 160 mg per day 2.
• Monitor lipid levels periodically and adjust the dosage of fenofibrate as necessary to achieve the targeted range 2.

From the Research

Management of Hypercholesterolemia and Hypertriglyceridemia

The patient's lab results indicate high levels of cholesterol (335 mg/dL) and triglycerides (465 mg/dL), with an HDL level of 45 mg/dL. The LDL and VLDL cholesterol calculations are unavailable due to high triglyceride levels (>400 mg/dL).

Lifestyle Modifications

• Changes in diet, exercise, reduction in body mass index, and abstinence from alcohol consumption are primary interventions for managing triglycerides ≥ 10 mmol/L, as seen in a case report where a patient reduced triglycerides from 44.94 mmol/L to 3.28 mmol/L through lifestyle modifications alone 3.
• A reduction in body weight of 5-10% can reduce triglycerides by approximately 20% 4.

Pharmacotherapy

• Statins are the first line of therapy for managing mild to moderate hypertriglyceridemia (1.7-5.6 mmol/L [150-499 mg/dL]) and can reduce mean triglyceride levels by up to 18% 5.
• Fibrates, niacin, or long-chain omega-3 fatty acids may be added if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist despite high-intensity statin therapy 5, 4.
• Omega-3 fatty acids may be a well-tolerated and effective alternative to fibrates and niacin for reducing triglyceride levels 5, 6.

Treatment Goals

• For patients with TG <400 mg/dL, the primary goal is to reduce low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol, with most guidelines recommending statin therapy 4.
• When TG is ≥500 mg/dL, the primary goal is to reduce TG levels to lower the risk of pancreatitis, and statin therapy in combination with a fibrate or long-chain omega-3 fatty acid may be required 4.